Provider Demographics
NPI:1669470431
Name:GANCAYCO, JAMIE (MD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:
Last Name:GANCAYCO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:781 S MCHENRY AVE
Mailing Address - Street 2:
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7444
Mailing Address - Country:US
Mailing Address - Phone:815-459-2200
Mailing Address - Fax:815-788-9263
Practice Address - Street 1:781 S MCHENRY AVE
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7444
Practice Address - Country:US
Practice Address - Phone:815-459-2200
Practice Address - Fax:815-788-9263
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2021-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101835207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL215184001OtherMEDICARE PTAN
IL962341OtherMEDICARE GROUP PTAN
IL036101835Medicaid
IL04532206OtherBLUE CROSS BLUE SHIELD
IL04532206OtherBLUE CROSS BLUE SHIELD